Less than a quarter of respondents said they were asked about social, emotional issues

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Anxiety and clinical depression are about twice as prevalent in rheumatic diseases as in the general population but the healthcare system very often failed to provide psychological support, according to a U.K. survey.

Despite both European and U.S. guidelines recommending psychological support, less than a quarter of survey respondents said they were asked about social and emotional issues.

Patients in Britain with inflammatory arthritis had a high need for psychological support, but the healthcare system very often failed to provide those services, according to survey results.

Despite European and U.S. guidelines recommending psychological support, less than a quarter (23%) of 1,210 respondents said they were asked about social and emotional issues, reported Emma Dures, PhD, of the Bristol Royal Infirmary in England, and colleagues.

"The preference is for delivery from rheumatology clinicians and [general practitioners], and research should establish whether they have the skills and resources to meet patients' needs," they wrote in the Annals of the Rheumatic Diseases.

The authors noted that anxiety and clinical depression in rheumatic diseases are about twice as prevalent as in the general population, referring to a study of recently diagnosed patients who reported that at all points during 10-year follow-up, 20% to 30% had clinically important levels of anxiety and 5% to 13% had clinically important levels of depression.

Milder negative affective states such as low mood, sorrow, worry, irritability, apprehension, insomnia, and restlessness are estimated to affect up to 65% of patients, they added.

"Evidence suggests that in [rheumatoid arthritis], disease status and disease activity alone are not good predictors of psychological distress, and factors such as illness beliefs, locus of control and coping strategies are influential," Dures and colleagues wrote

The current survey was done at six hospitals and one national RA charity. Of the respondents with inflammatory arthritis (1,210 of 2,280), 74% female and had a mean age of 59. Their mean patient global assessment of disease activity score was 5.5, and mean disease duration was less than 5 years in 41%, 5-10 years in 20%, and longer than 10 years in 39%.

The 10-minute questionnaire, which included patient input in design and interpretation of results, polled patients on personal experience of social and emotional support from their rheumatology teams and preferences in psychological support, including type of service, provider, mode of delivery, and areas where help was wanted.

Almost half (46%) stated they would welcome the chance to discuss the psychological aspects of their disease. Furthermore, 66% of respondents said they would use a self-management/coping clinic if such were available.

Areas where they indicated that they wanted help in managing difficulties included pain and fatigue (82%), emotions (57%), managing work and leisure (52%), relationships (37%), and depression (34%). Only 6% reported that social and emotional considerations were not relevant.

Respondents overwhelmingly favored face-to-face delivery of psychological support as opposed to computer-based interventions, according to the authors.

One limitation of the survey was the considerable variation in response rates across sites. No differences emerged, however, between the six hospital sites in relation to patients' preferences for psychological support. Furthermore, the percentage of white British respondents was higher than in the inflammatory arthritis population as a whole, suggesting that patients from other ethnic backgrounds were less likely to respond.

"This has implications for the design of support services, as there is evidence that ethnicity influences support priorities and needs," Dures' group noted.

They also pointed to potential bias in that patients with greater psychological support needs may have been more likely to complete the questionnaire. And while the survey asked about preferred types of support, how this would translate into actual patient uptake in clinical practice is not known, they acknowledged.

Candace Feldman, MD, MPH, of Boston's Brigham and Women's Hospital and Harvard Medical School, both in Boston, told MedPage Today that "this study highlights the importance of patient-provider communication around social and emotional issues. While often challenging in the context of addressing complicated medical issues during compressed clinic visits, the importance of these issues to patients, and ultimately to their disease management and outcomes, warrants further attention and action."

An ongoing study at Brigham and Women's arthritis center has found that although patients with chronic rheumatic diseases frequently report symptoms of depression and anxiety when taking a survey, these symptoms are often not discussed during the course of their routine rheumatology appointments, she noted.

Feldman stressed that the issue of face-to-face delivery of support is particularly relevant as the use of technology such as smartphone applications in clinical practice increases. She pointed out that limited availability of mental health services may constrain rheumatologists' referrals and limit their willingness to engage in conversations about psychosocial issues.

"Both better training of rheumatologists and nurses in these issues, and greater allocation of resources to mental health services that are available to all patients regardless of insurance status, would likely improve communication around psychological support between patients and providers," Feldman said.

She also noted that in the U.S., "resources to support the psychological health of individuals with chronic rheumatic diseases may be limited by shortages of mental health providers, lack of integrated care teams in many rheumatology clinics, lack of time and training of rheumatologists to provide these services, and the limited number and accessibility of local support groups."

The study was funded by Arthritis Research U.K.

Dures and co-authors disclosed no relevant relationships with industry.

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